If your insurance company uses the American Chiropractic Network (ACN) or OptumHealth chiropractic panel, this form is necessary for you to complete for your first office visit. You may also be required to fill out this form periodically as you receive care at Arbor View Chiropractic Center
If you have Medicare insurance, you will need to print this form and bring it with you to Arbor View Chiropractic Center on your first office visit. This is the Advance Beneficiary Notice of Noncoverage (ABN) form and serves to identify that there may be services used in your treatment that aren't covered by your Medicare insurance.
The auto accident history form is comprised of two pages. Please fill out these documents as completely as you can. Please be as specific regarding the details of the accident.